Management of intrapulmonary hemorrhage in patients undergoing pulmonary thrombo-endarterectomy.

Massive pulmonary hemorrhage during pulmonary thromboendarterectomy (PTE) can be managed by a conservative approach with mechanical ventilatory support, positive end-expiratory pressure, lung isolation, reversal of heparin, and correct of coagulopathy. We present three challenging cases that developed intrapulmonary hemorrhage during/after PTE and managed successfully. The first patient had bleeding from the bronchial artery and right internal mammary collaterals, which was managed by coil-embolization. The second patient had a breach in the blood airway barrier in the right upper lobar segment of the lung, and the repair was done using a surgical absorbable hemostat. The third patient developed reperfusion injury, he was instituted on veno-venous extracorporeal membranous oxygenation, a week later, the patient recovered completely. An algorithm was adopted and modified to our requirements; all the 3 challenging intrapulmonary hemorrhage cases were successfully managed. This algorithm can be used for satisfactory outcomes in patients who suffer intrapulmonary hemorrhage during PTE.

Methemoglobinemia Unmasked by Use of Sodium Nitroprusside and Hypothermia in a Case of Chronic Thromboembolic Pulmonary Hypertension During Pulmonary Endarterectomy: A Case Report.

In performing pulmonary endarterectomy (PEA) for a patient with chronic thromboembolic pulmonary hypertension (CTEPH), we encountered methemoglobinemia that was unmasked by hypothermia while on cardiopulmonary bypass (CPB). The patient on dapsone therapy for antiphospholipid antibody syndrome had developed acquired methemoglobinemia that went undiagnosed because her cyanosis was believed to be due to CTEPH and the resulting ventilation-perfusion (V/Q) mismatch. Although pharmacological triggers for methemoglobin are well known, causation by hypothermia is not described. Monitoring saturation while on CPB was challenging because of nonpulsatile blood flow but was overcome using cerebral oximetry.

A novel treatment for pulmonary hemorrhage during thromboendarterectomy surgery.

Injury to the pulmonary artery during thromboendarterectomy is a rare but potentially fatal complication with no reported surgical techniques to combat it. Treatment is only supportive and morbidity is high. We report the intraoperative diagnosis and surgical management of pulmonary hemorrhage in 3 patients after pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension.

Hydrochemical assessment of tropical springs--a case study from SW India.

The paper deals with the hydrochemical characterization and water quality assessment of springs emerging from the Archaean crystalline basements at the foothills of Western Ghat mountains in the highlands and Neogene sedimentary formations in the coastal lowlands of Kerala in south west India. A total of 19 springs from two important river basins of southern Kerala such as Ithikkara and Kallada river basins were studied for 18 physico-chemical (temperature, pH, electrical conductivity (EC), total dissolved solids (TDS), dissolved oxygen (DO), total hardness (TH), Na(+), K(+), Ca(2+), Mg(2+), CO3 (2-), HCO3 (-), Cl(-), SO4 (2-) , NO3 (-), SiO2, Fe(2+), and F(-) ) as well as bacteriological parameters. The discharge computations show that free-falling type of springs in the area discharge about 256.23 million liters of water a year. A comparative study between the spring water samples of highland and lowland regions reveal that the quality of spring water, except pH and bacteriological contents, satisfies the standards set by the Bureau of Indian Standards and World Health Organization for drinking water. Spring water samples collected from the lowlands register high value of Na(+) and Cl(-) compared with the highlands. Bicarbonate, Ca(2+), Mg(2+), and K(+) values are high in highland than lowland springs. The present study reveals that the spring water sources in the region can be developed as an alternate source for drinking water, provided pH correction and proper disinfection are done prior to its end use.

Entrapped central venous catheter after mitral valve replacement and its surgical retrieval.

Central venous pressure monitoring line insertion is routine prior to the conduct of cardiac surgery, and in rare instances, malposition can contribute to operative complications. We describe here how a central venous line lying in the right atrium became caught in a left atrial (LA) closure suture during a mitral valve replacement. The opening of the LA suture line is highly unsafe without cardiopulmonary bypass (CPB) because of the possibility of systemic air embolism, but by employing an ingenious method of suturing over and unravelling the continuous sutures closing the left atrium, it was possible to surgically retrieve it without the use of a CPB.

Haemodynamic response to endotracheal intubation in coronary artery disease: Direct versus video laryngoscopy.

Endotracheal intubation involving conventional laryngoscopy elicits a haemodynamic response associated with increased heart and blood pressure. The study was aimed to see if video laryngoscopy and endotracheal intubation has any advantages over conventional laryngoscopy and endotracheal intubation in patients with coronary artery disease. Thirty patients suffering from coronary artery disease scheduled for elective coronary artery bypass grafting (CABG) were studied. The patients were randomly allocated to undergo either conventional laryngoscopy (group A) or video laryngoscopy (group B). The time taken to perform endotracheal intubation and haemodynamic changes associated with intubation were noted in both the groups at different time points. The duration of laryngoscopy and intubation was significantly longer in group B (video laryngoscopy) when compared to group A patients. However, haemodynamic changes were no different between the groups. There were no events of myocardial ischaemia as monitored by surface electrocardiography during the study period in either of the groups. In conclusion, video laryngoscopy did not provide any benefit in terms of haemodynamic response to laryngoscopy and intubation in patients undergoing primary CABG with a Mallampatti grade of <2.

Transesophageal echocardiaography evaluation of thoracic aorta.

Trans-esophageal echocardiaography is a sensitive, minimally invasive, diagnostic tool which gives real time functional image of the aorta. It helps in the diagnosis of pathologies of aorta like atherosclerosis, aneurysm and aortic dissection.